Will intermediate care be the undoing of the NHS?
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The practice of selling Brucella-infected cattle in the open market appears to be widespread in Britain and is increasing. The introduction of an infected cow into a herd can cause serious economic loss to the farmer and often compels him to resell despite the risk of spreading the infection. It is suggested that markets should be more closely controlled by veterinary surgeons; certificates of freedom from brucellosis should accompany animals for sale; and some compensation should be paid to prevent infected animals from being sold.
In May of this year after three years' work an advisory panel of the B.M.A., with Dr. I. M. Jones in the chair, produced a report on Health Services Financing.(1) A summary appeared in the Annual Report of Council(2) and a preliminary discussion on the report was held at the B.M.A.'s Annual Representative Meeting in July.(3) A full debate was deferred until the committees, divisions, and branches of the Association had had an opportunity to discuss the proposals. Nearly half of the book consists of appendices, commissioned from several economists, which cover the N.H.S. and the health services of 14 Western and some Eastern European countries. Below Professor Dennis Lees reviews these appendices, which formed a major source of information for the authors of the report and therefore have an important bearing on their conclusions.
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OBJECTIVE: To determine whether asking for a $5.00 donation for bicycle helmets, compared with distribution free of charge, would affect helmet use among children receiving helmets and an educational intervention from public health clinics. SETTING: Six public health clinic sites in King County, Washington. METHODS: Six participating clinic sites were randomly assigned to either free helmet distribution or to a $5.00 suggested donation for the helmets, stratified by whether a helmet law was in place. Three sites were assigned to each arm. Children who were between 6 and 12 years of age and who reported riding bicycles, but having no bicycle helmets, were eligible. Clinicians distributed helmets and delivered an educational intervention to 506 eligible children, or siblings of children seen at the clinic between March and July 1993. Parents were contacted after helmet distribution to ascertain helmet use. RESULTS: 82% of children whose parents were asked for a copayment and 77% of children who received free helmets were reported to wear their helmets every time they rode their bicycles (p=0.20). The adjusted odds ratio for the association between copayment compared with free helmets and helmet use was 1.66 (95% confidence interval 0.94 to 2.92). CONCLUSIONS: Helmet use was not significantly different among children whose parents were asked for a small copayment, compared with those who received helmets free. Use of copayments can increase helmet use by increasing the number of helmets given to low income children.
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STUDY OBJECTIVE: To test the validity of proxy measures of household wealth and income that can be readily implemented in health surveys in rural Africa. DESIGN: Data are drawn from four different integrated household surveys. The assumptions underlying the choice of wealth proxy are described, and correlations with the true value are assessed in two different settings. The expenditure proxy is developed and then tested for replicability in two independent datasets representing the same population. SETTING: Rural areas of Mali, Malawi, and Côte d'Ivoire (two national surveys). PARTICIPANTS: Random sample of rural households in each setting (n=275, 707, 910, and 856, respectively). MAIN RESULTS: In both Mali and Malawi, the wealth proxy correlated highly (r>/=0.74) with the more complex monetary value method. For rural areas of Côte d'Ivoire, it was possible to generate a list of just 10 expenditure items, the values of which when summed correlated highly with expenditures on all items combined (r=0.74, development dataset, r=0. 72, validation dataset). Total household expenditure is an accepted alternative to household income in developing country settings. CONCLUSIONS: It is feasible to approximate both household wealth and expenditures in rural African settings without dramatically lengthening questionnaires that have a primary focus on health outcomes.